| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,591 |
2,582 |
$294K |
| D0272 |
Bitewings - two radiographic images |
2,016 |
2,011 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
248 |
$37K |
| D1120 |
Prophylaxis - child |
2,784 |
2,777 |
$24K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
509 |
294 |
$17K |
| D1351 |
Sealant - per tooth |
315 |
50 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,911 |
2,614 |
$9K |
| D1206 |
Topical application of fluoride varnish |
2,714 |
2,710 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
124 |
37 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
2,814 |
2,781 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
38 |
$4K |
| D0274 |
Bitewings - four radiographic images |
172 |
172 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$2K |
| D2140 |
|
16 |
12 |
$575.07 |